LESSON ASSIGNMENT LESSON 1 Nursing Care Related to the Cardiovascular System. TEXT ASSIGNMENT Paragraphs 1-1 through 1-44. LESSON OBJECTIVES After completing this lesson, you should be able to: 1-1. Name the two fluid transportation systems of the circulatory system. 1-2. Identify the valves, chambers, and blood vessels of the heart. 1-3. Describe the flow of blood through the heart. 1-4. State the function of the coronary arteries. 1-5. Define pulse. 1-6. Define blood pressure. 1-7. State two purposes of cardiac fluoroscopy. 1-8. Define cardiac catheterization. 1-9. Identify the five major waves of an ECG. 1-10. State the purposes of an ECG. 1-11. Identify the locations for the placement of limb and chest electrodes when performing a standard 12-lead ECG. 1-12. Define pulse deficit. 1-13. Identify the three characteristics that should be noted when taking a patient's pulse. 1-14. List four factors that may affect a patient's

pulse. 1-15. Define systolic blood pressure. 1-16. Define diastolic blood pressure. 1-17. State three factors that affect blood pressure. 1-18. Define pulse pressure. 1-19. Define coronary artery disease. 1-20. List six modifiable risk factors. 1-21. Define coronary heart disease. 1-22. Define arteriosclerosis. 1-23. Define arteriosclerosis. 1-24. State the cause of angina pectoris. 1-25. Define AMI. 1-26. State the symptoms of myocardial infarction. 1-27. Define heart failure. 1-28. Explain the difference between left sided heart failure and right sided heart failure. 1-29. Explain the difference between primary and secondary hypertension.

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1-30. List four topics included in-patient education for hypertension. 1-31. Define infective endocarditic. 1-32. List three categories of needs that must be assessed during the preoperative period for a CV surgery patient. 1-33. State four complications of cardiovascular surgery. 1-34. State two signs of thrombophlebitis. 1-35. Define cardiac tamponade. 1-36. Describe at least three aspects of post-op nursing for the cardiovascular surgery patient. 1-37. Define cardiac arrest. 1-38. List six causes of sudden cardiac death. 1-39. List three responsibilities of the nursing paraprofessional in relation to cardiac arrest. 1-40. List at least five items found in a crash cart. SUGGESTION After studying the assignment, complete the exercises at the end of this lesson. These exercises will help you achieve the lesson objectives.

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LESSON 1

NURSING CARE RELATED TO THE CARDIOVASCULAR SYSTEM

Section I. ANATOMY AND PHYSIOLOGY 1-1. INTRODUCTION The circulatory system has two major fluid transportation systems, the cardiovascular (CV) 00system and the lymphatic system. a. Cardiovascular System. This system, which contains the heart and blood vessels, is a closed system, transporting blood to all parts of the body. Blood flowing through the circuit formed by the heart and blood vessels (see Figure 1-1) brings oxygen, food, and other chemical elements to tissue cells and removes carbon dioxide and other waste products resulting from cell activity. b. Lymphatic System. This system, which provides drainage for tissue fluid, is an auxiliary part of the circulatory system, returning an important amount of tissue fluid to the blood stream through its own system of lymphatic vessels. 1-2. THE HEART The heart, designed to be a highly efficient pump, is a four-chambered muscular organ, lying within the chest, with about 2/3 of its mass to the left of the midline. It lies in the pericardial space in the thoracic cavity between the two lungs. In size and shape, it resembles a man's closed fist. Its lower point, the apex, lies just above the left diaphragm. Refer to Figure 1-2 as you continue to read. a. Heart Layers. The pericardium is a double walled sac enclosing the heart. The outer fibrous surface gives support, and the inner lining prevents friction as the heart moves within its protecting jacket. The lining surfaces of the pericardial sac produce a small amount of pericardial fluid needed for lubrication to facilitate the normal movements of the heart. b. Heart Wall. The walls of the heart is composed of three distinct layers an outer epicardium- which corresponds to the visceral pericardium it protects the heart by reducing friction, a middle layer the myocardium consist mostly of cardiac muscle tissue that pumps blood out of the heart chambers, an inner layer endocardium consist of epithelium and connective tissue that contains many elastic and collagenous fibers.

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Figure 1-1. The circulatory system.

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Figure 1-2. The heart.

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c. Heart Chambers. There are four chambers in the heart. These chambers are essentially the same size. The upper chambers, called the atria, are seemingly smaller than the lower chambers, the ventricles. The apparent difference in total size is due to the thickness of the myocardial layer. The right atrium communicates with the right ventricle; the left atrium communicates with the left ventricle. The septum (partition), dividing the interior of the heart into right and left sides, prevents direct communication of blood flow from right to left chambers or left to right chambers. This is important, because the right side of the heart receives un-oxygenated blood returning from the systemic (body) circulation. The left side of the heart receives oxygenated blood returning from the pulmonary (lung) circulation. The special structure of the heart keeps the blood flowing in its proper direction to and from the heart chambers. d. Heart Valves. The four chambers of the heart are lined with endocardium. At each opening from the chambers this lining folds on itself and extends into the opening to form valves. These valves allow the blood to pass from a chamber but prevent its return. The atrioventricular valves, between the upper and lower chambers, are within the heart itself. The semilunar valves are within arteries arising from the right and left ventricles. (1) Atrioventricular valves. The tricuspid valve is located between the right atrium and right ventricle. It has three flaps or cusps. The bicuspid valve or mitral valve is located between the left atrium and left ventricle. It has two flaps or cusps. (2) Semilunar valves. The pulmonary semilunar (half-moon shaped) valve is located at the opening into the pulmonary artery that arises from the right ventricle. The aortic semilunar valve is located at the opening into the aorta that arises from the left ventricle. 1-3. FLOW OF BLOOD THROUGH THE HEART It is helpful to follow the flow of blood through the heart in order to understand the relationship of the heart structures. Remember, the heart is the pump and is also the connection between the systemic circulation and pulmonary circulation. All the blood returning from the systemic circulation must flow through the pulmonary circulation for exchange of carbon dioxide for oxygen. Blood from the upper part of the body enters the heart through the superior vena cava and blood from the lower part of the body enters through the inferior vena cava. a. Blood from the superior vena cava and inferior vena cava enters the heart at the right atrium. The right atrium contracts, and blood is forced through the open tricuspid valve into the relaxed right ventricle. b. As the right ventricle contracts, the tricuspid valve is closed, preventing back flow into the atrium. The pulmonary semilunar valve opens as a result of the force and movement of the blood, and the right ventricle pumps the blood into the pulmonary artery.

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c. The blood is carried through the lung tissues, exchanging its carbon dioxide for oxygen in the alveoli. This oxygenated blood is collected from the main pulmonary veins and delivered back to the left side of the heart to the left atrium. d. As the left atrium contracts, the oxygenated blood flows through the open bicuspid (mitral) valve into the left ventricle. e. As the left ventricle contracts, the bicuspid valve is closed. The aortic semilunar valve opens as a result of the force and movement of the blood, and the left ventricle pumps oxygenated blood through the aortic semilunar valve into the aorta, the main artery of the body. Oxygenated blood now starts its flow to all of the body cells and tissues. The systemic circulation starts from the left ventricle, the pulmonary circulation from the right ventricle. 1-4. BLOOD AND NERVE SUPPLY OF THE HEART a. Coronary Arteries. The heart gets its blood supply from the right and left coronary arteries (Figure 1-3). These arteries branch off from the aorta just above the Aortic Valve, then subdivide into many smaller branches within the heart muscle. If any part of the heart muscle is deprived of its blood supply through interruption of blood flow through the coronary arteries and their branches, the muscle tissue deprived of blood cannot function and will die. This is called myocardial infarction (MI). Blood from the heart tissue is returned by coronary veins to the right atrium via the coronary sinus.

Figure 1-3. The coronary arteries.

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b. Nerve Supply. The nerve supply to the heart is from two sets of nerves originating in the medulla of the brain. The nerves are part of the involuntary (autonomic) nervous system. One set, the branches from the vagus nerve, keeps the heart beating at a slow, regular rate. The other set, the cardiac accelerator nerves, speeds up the heart. The heart muscle has a special ability; it contracts automatically, but the nerve supply is needed to provide an effective contraction for blood circulation. Within the heart muscle itself, there are special groups of nerve fibers that conduct impulses for contraction. These groups make up the conduction system of the heart. When the conduction system does not operate properly, the heart muscle contractions are uncoordinated and ineffective. The impulses within the heart muscle are tiny electric currents, which can be picked up and recorded by the electrocardiogram, the ECG. 1-5. BLOOD VESSELS The blood vessels are the closed system of tubes through which the blood flows. The arteries and arterioles are distributors. The capillaries are the vessels through which all exchange of fluid, oxygen, and carbon dioxide takes place between the blood and tissue cells. The capillaries are the smallest of these vessels but are of greatest importance functionally in the circulatory system. The venules and veins are collectors, carrying blood back to the heart. a. The Arteries and Arterioles. The system of arteries and arterioles is like a tree, with the large trunk, the aorta, giving off branches that repeatedly divide and subdivide. Arterioles are very small arteries, about the diameter of a hair. By way of comparison, the aorta is more than one inch in diameter. An artery wall has a layer of elastic, muscular tissue that allows it to dilate and constrict. When an artery is cut, this wall does not collapse, and bright red blood escapes from the artery in spurts. b. Capillaries. Microscopic in size, capillaries are so numerous that there is at least one or more near every living cell. A single layer of endothelial cells forms the walls of a capillary. Capillaries are the essential link between arterial and venous circulation. The vital exchange of substances between the capillary blood and the tissue cells takes place through the capillary wall. Blood starts its route back to the heart as it leaves the capillaries. c. Veins. Veins have thin walls and valves. Formed from the inner vein lining, these valves prevent blood from flowing back toward the capillaries. Venules, the smallest veins, unite into veins of larger and larger size as the blood is collected for return to the heart. The superior vena cava, collecting blood from all regions above the diaphragm and the inferior vena cava, collecting blood from all regions below the diaphragm, return the venous blood to the right atrium of the heart. Superficial veins lie close to the surface of the body and can be seen through the skin.

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1-6. PULSE AND BLOOD PRESSURE a. Pulse. This is a characteristic associated with the heartbeat and the subsequent wave of expansion and recoil set up in the wall of an artery. Pulse is defined as the alternate expansion and recoil of an artery. With each heartbeat, blood is forced into the arteries causing them to dilate (expand). Then the arteries contract (recoil) as the blood moves further along in the circulatory system. The pulse can be felt at certain points in the body where an artery lies close to the surface. The most common location for feeling the pulse is at the wrist, proximal to the thumb on the palm side of the hand (radial artery). Alternate locations are in front of the ear (temporal artery), at the side of the neck (carotid artery), and on the top (dorsum) of the foot (dorsalis pedis). b. Blood Pressure. The force that blood exerts on the walls of vessels through which it flows is called blood pressure. All parts of the blood vascular system are under pressure, but the term blood pressure usually refers to arterial pressure. Pressure in the arteries is highest when the ventricles contract during systole. Pressure is lowest when the ventricles relax during diastole. The brachial artery, in the upper arm, is the artery usually used for blood pressure measurement. 1-7. LYMPHATIC SYSTEM The lymphatic system consists of lymph, lymph vessels, and lymph nodes. The spleen belongs, in part, to the lymphatic system. Unlike the cardiovascular system, the lymphatic system has no pump to move the fluid that collects, but muscle contractions and breathing movements aid in the movement of lymph through its channels and its return to the blood stream. a. Lymph and Tissue Fluid. Lymph, fluid found in the lymph vessels, is clear and watery and is similar to tissue fluid, which is the colorless fluid that fills the spaces between tissues, between the cells of organs, and between cells and connective tissues. Tissue fluid serves as the "middleman" for the exchange between blood and body cells. Formed from plasma, it seeps out of capillary walls. The lymphatic system collects tissue fluid, and as lymph, the collected fluid is started on its way for return to the circulating blood. b. Lymph Vessels. Starting as small blind ducts within the tissues, the lymphatic vessels enlarge to form lymphatic capillaries. These capillaries unite to form larger lymphatic vessels, which resemble veins in structure and arrangement. Valves in lymph vessels prevent backflow. Superficial lymph vessels collect lymph from the skin and subcutaneous tissue; deep vessels collect lymph from all other parts of the body. The two largest collecting vessels are the thoracic duct and the right lymphatic duct. The thoracic duct receives lymph from all parts of the body except the upper right side. The lymph from the thoracic duct drains into the left subclavian vein, at the root of the neck on the left side. The right lymphatic duct drains into a corresponding vein on the right side.

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c. Lymph Nodes. Occurring in groups up to a dozen or more, lymph nodes lie along the course of lymph vessels. Although variable in size, they are usually small oval bodies that are composed of lymphoid tissue. Lymph nodes act as filters for removal of infective organisms from the lymph stream. Important groups of these nodes are located in the axilla, the cervical region, the sub maxillary region, the inguinal (groin) region, and the mesenteric (abdominal) region. d. Infection and the Lymphatic System. Lymph vessels and lymph nodes often become inflamed as the result of infection. An infection in the hand may cause inflammation of the lymph vessels as high as the axilla (armpit). A sore throat may cause inflammation and swelling of lymph nodes in the neck (submandibular nodes below the jaw and cervical nodes posteriorly). e. Spleen. The largest collection of lymphoid tissue in the body, the spleen is located high in the abdominal cavity on the left side, below the diaphragm and behind the stomach. It is somewhat long and ovoid (egg- shaped). Although it can be removed (splenectomy) without noticeable harmful effects, the spleen has useful functions, such as serving as a reservoir for blood and red blood cells.

Section II. DIAGNOSTIC PROCEDURES 1-8. INTRODUCTION a. Cardiovascular diagnostic tests and examinations are conducted by order of the physician to help him determine the nature of the specific disease condition. Many of these tests or examinations may be repeated at intervals to determine the patient's progress or response to prescribed treatment. While some are performed on the nursing unit, many others are conducted only in special laboratories and hospital clinics. b. The nursing paraprofessional's role in assisting with diagnostic tests and collection of specimens will vary, depending upon the test, the specimen, the condition of the patient, and the local situation and policy. Although they may seldom perform any part of the test themselves, they should be acquainted with those commonly performed in order to give intelligent patient care and appropriate assistance to the doctor, nurse, or technician. In general, they should know: (1) How and why the procedure is done and what, if any, reaction is expected from it. (2) What explanation and physical care the patient should have before, during, and after the procedure. The informed, prepared patient is more apt to cooperate and to tolerate any inconvenience or discomfort incidental to the test.

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(3) What equipment, clean or sterile, must be provided when assisting with the procedure and how to care for used equipment following the procedure. (4) The role of the assistant in relation to that of the doctor, nurse, or technician performing the test. 1-9. GENERAL PREPARATORY MEASURES FOR PROCEDURES PERFORMED

OFF THE NURSING UNIT Procedures vary from one hospital to another concerning nursing unit preparation of patients who are to be sent or escorted to clinics, laboratories, radiology, or operating rooms. These various departments set their own standing operating procedure in accordance with local directives and issue instructions to the nursing units. These instructions and the doctor's orders for the particular patient must be carried out carefully to ensure the best results for the patient. A few general rules to remember are: a. Prepare the Patient Mentally. Tell the patient briefly what to expect and explain his role in the preparation. Mental preparation of the patient gives him emotional security and gains his confidence and cooperation. CAUTION: Always verify with the nurse or doctor what information you may give to

the patient. b. Prepare the Patient Physically. Have the patient clean, properly dressed, and protected from exposure or drafts. Make sure that any specific preparation ordered has been accomplished, such as medication, rest for a required period, or restriction on food or liquids. c. Have the Right Patient in the Right Place at the Right Time. If he is an ambulatory patient, give him specific directions on how to reach the clinic or laboratory. Transport an otherwise ambulatory patient who has received a sedative or other pretreatment medication in a wheelchair or on a stretcher. The responsibility of nursing unit personnel accompanying the patient ends only after the patient is placed in the care of the personnel who are to perform the procedure. d. Be Sure That Forms Are Signed. Ensure that SF 522 (Clinical Record--Authorization for Administration of Anesthesia and for Performance of Operations and Other Procedures), if required, is signed by the patient or the patient's sponsor and witnessed by a medical officer, nurse, or other suitable individual. e. Send the Patient's Clinical Record and X-rays to the Off-Unit Examination Areas. Enclose the record in a sealed manila envelope to safeguard the contents. Check to see that the records are returned with the patient.

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1-10. GENERAL NURSING CARE DURING DIAGNOSTIC PROCEDURES PERFORMED ON THE NURSING UNIT

In addition to the general rules mentioned in the previous paragraph, you should: a. Assist the physician as required. This may involve obtaining equipment, opening sterile trays, preparing a sterile field, pouring solutions, preparing the patient's skin, positioning the patient, draping the patient, and assisting the physician in the performance of the procedure. b. Reassure the patient and make him as comfortable as possible. NOTE: For some patients and some procedures, two assistants will be needed one to support and observe the patient and one to assist the doctor. c. If a specimen is taken, attach to the specimen container a prepared label identifying the patient by name and register number, ward, date, and test. Forward the specimen to the laboratory immediately with the proper laboratory request slip. 1-11. GENERAL NURSING CARE FOLLOWING DIAGNOSTIC PROCEDURES a. Return the patient to his bed by the means ordered. b. Check the orders of the physician who performed the procedure. Observe and report any unusual reactions of the patient. If there are no orders pertaining to taking vital signs, accomplish this nursing measure according to standard nursing unit procedures. c. Use appropriate measure to relieve discomfort or pain. d. If the patient has been sedated or anesthetized, ensure bed rest until he has completely reacted. Tell him to stay in bed and to signal for any needs. Use side rails according to standard procedures. Ensure the call light is with in reach of the patient. e. If the procedure involves the patient's diet, notify food service to serve, modify, or cancel his meal as appropriate. f. Explain to the patient that he will be notified when he may resume his normal regime. When this time arrives, inform him promptly. g. Record the following information in the nursing notes. (1) Date and time. (2) Type of procedure.

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(3) Where and by whom performed. (4) Disposition of specimen, if taken. (5) Significant observations on patient's reaction such as pain, discomfort, and apprehension. (6) Patient's vital signs before and after the procedure (when these are required). 1-12. FLUOROSCOPY Fluoroscopy shows the heart in action and is used more often than other x-ray methods in cardiologic examinations. Fluoroscopy is used to look for abnormal configuration, tumors, and calcifications in the heart, aorta, and pulmonary vessels, to find congestion of the lungs, and to detect pleural or pericardial effusions. During examination of the heart under fluoroscopy, barium is given by mouth so the outline of the esophagus can be seen. An enlarged left atrium pushes the esophagus aside as it becomes larger. There is no preparation of the patient for this examination. 1-13. INTRAVENOUS ANGIOCARDIOGRAPHY This is a procedure in which an opaque medium is injected into a vein followed by a rapid series of x-ray pictures taken of the course of the medium through the heart, to the lungs, back to the heart, and out through the aorta. The dosage of contrast media is calculated according to the kilograms of body weight. The solution is injected through a large bore (12 gauge) needle held in position in the vein, usually by a "cut down." Speed of injection is imperative, since the solution must pass through the heart in a large bolus to make possible a good examination. The solution is injected after the patient has been instructed to inhale deeply. The inspiration is held for the entire series of x-rays. a. This diagnostic method is recognized for precision in detecting congenital cardiac defects. Individual chambers of the heart are visualized, pathways for the blood stream are demonstrated, and chamber enlargement can be seen. b. The opaque medium may cause a flushing sensation as it flows through the body. If necessary, the studies may be conducted under mild anesthesia. After one complete circulation, the opaque media is so diluted that it is no longer visible by x-ray. c. No special preparation of the patient is necessary unless anesthesia is to be given. In that event, food may be withheld prior to the studies. A record of the patient's weight should be sent to the x-ray department with him.

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1-14. AORTOGRAM The aorta and its branches are studied by the injection of a contrast medium through a plastic catheter or with a needle directly into the aorta. Terms used in connection with the aortogram are retrograde aortogram (retrograde meaning against the direction of blood flow) and translumbar aortogram (meaning the injection is made below the twelfth rib and to the left of the spine). No preparation of the patient is necessary. 1-15. CARDIAC CATHETERIZATION This is a procedure in which a radiopaque catheter is manipulated through the heart under fluoroscopic observation. The exterior end of the catheter is connected by a three-way stopcock to a saline filled regulated drip system that also contains a pressure gauge (strain gauge) and a camera. During the procedure the blood pressures within the heart are automatically transmitted to the strain gauge that, in turn, transmits the pressure to the camera recording the findings on photographic film. Samples of blood are also withdrawn from the heart chambers and great vessels. The samples are analyzed for oxygen content. a. The pressures within the heart indicate any existing strain placed on individual heart chambers. The oxygen content indicates whether the blood is circulating directly through the heart or whether the blood is being shunted because of an anatomical defect. b. During the entire procedure an electrocardiograph and an electro-tachometer is recording readings on photographic paper. The electro-cardio-tachometer is connected by leads that operate, as do those of the electrocardiograph and instantaneously records the heart rate. It also contains a small light that flashes on with each heartbeat, thus enabling the doctor to observe in the dark the condition of the patient. c. There are several routes used for the catheter approach to the heart. Not long ago only the right side of the heart was studied by catheterization. The cardiac catheter was inserted by means of a "cut-down" into the antecubital vein of either arm, then manipulated through the innominate vein, superior vena cava, right atrium, tricuspid valve, right ventricle, semilunar valve, and pulmonary artery. The cardiac catheter may also be placed in the right or left femoral vein, then manipulated through the inferior vena cava it may then follow the same path as the catheter entered through the antecubital vein. d. Several studies also include the left side of the heart. The approach is made directly to the left atrium by means of an 18-gauge, 6-inch needle with a stylet through the patient's back directly into the heart. After the tip of the needle is placed in the left atrium, the stylet is removed and the catheter is manipulated into the left atrium, left ventricle, and the ascending aorta.

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e. Studies now also include the examination of both sides of the heart simultaneously through the transthoracic introduction of two needles, one in each atrium. f. The patient is taken to the fluoroscopy or cardiology department for the study. The entire procedure may last from 1 to 3 hours. The procedure is a painless one. The patient is prepared as follows: (1) Solid foods are withheld. Liquids are permitted up to 3 hours prior to the procedure. (2) Diphenhydramine and Valium may be given 30 minutes prior to the procedure. (3) A systemic antibiotic may be administered prophylacticly to prevent infection. (4) After the procedure the patient is returned to his nursing unit, remaining flat in bed for 24 hours or more. The vital signs and insertion site are checked every 10 minutes during the first hour, then every 30 minutes for 3 hours. The patient may be nauseated following the procedure. 1-16. ELECTROCARDIOGRAM a. The electrocardiogram (ECG or EKG) is a graphic recording of the electrical impulses produced in association with the heartbeat. Impulse formation and conduction produce weak electrical currents that spread throughout the entire body. By connecting certain points on the body to a recording instrument, these currents can be recorded as a graphic representation of the heartbeat, measured against time. Time is expressed on the special ECG graph paper by vertical and horizontal lines. b. Normally, each heartbeat is represented as five major waves: P, Q, R, S, and T. The Q,R, and S waves all represent the same portion of the heart and are referred to as a unit: the QRS complex. (1) The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. (2) The QRS complex represents the impulse traveling through the ventricles, at which time there is no heart contraction. (3) The T wave is produced by electrical recovery of the ventricles, at which time there is no heart contraction it represents ventricular repolarization.

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c. The standard ECG machine utilizes 12 "leads." These leads represent paths of electrical activity and are designated as leads I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, and V6. It is neither practical nor necessary to go into an explanation of leads in this text. To do so would require extensive explanation of electrophysiological principles. It will suffice to say that each lead senses and records the electrical impulses from different positions related to the heart's surface. Since each lead takes a different view of heart activity, it generates its own characteristic tracing. Wave abnormalities that appear in the different leads indicate damage or defects in particular portions of the heart muscle. d. The ECG provides quite a bit of valuable information for the small amount of effort involved in obtaining an ECG recording. It is a procedure that is completely noninvasive and without risk to the patient. It is easily performed by anyone with the proper training. The ECG provides information about the heart rate, rhythm, the condition of the myocardium, the presence of ischemia or necrosis, conduction abnormalities, the presence of certain drugs, and the effects of disturbed electrolytes. e. Because it does provide so much valuable information, it is important that the procedure be performed correctly. Correct procedure will vary depending upon the type of equipment used in your facility. Be sure to read the local standard operating procedures (SOP) and the manufacturer's instructions before attempting to use the equipment. Another important factor in correct performance is proper placement of the electrodes. Electrodes should be secured over a fleshy area, not over a bone, as bone interferes with the electrical impulse readings. In order to obtain accurate readings the patient may need to be shaved using a prep razor if the area where the electrodes are to be placed. Location of the electrodes is standard for all designs of ECG equipment. (1) Leg electrodes are best placed on the medial or lateral aspect of the calf to avoid contact with bone. (2) Arm electrodes are best placed on the inner aspect of the arm or forearm, several inches above or below the antecubital space. (3) Chest electrodes are placed as follows. Remember to place the electrodes over the intercostal spaces, not over the ribs. (a) V1: 4th intercostal space at the right sternal border. (b) V2: 4th intercostal space at the left sternal border. (c) V3: Halfway between V2 and V4. (d) V4: 5th intercostal space at the midclavicular line.

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(e) V5: 5th intercostal space at the anterior axillary line. (f) V6: 5th intercostal space at the midaxillary line. 1-17. STRESS TEST Stress testing or exercise testing is done to assess cardiac function. Stress testing is accomplished by having the patient climb stairs, pedal a stationary bicycle, or walk a treadmill. The exercise is gradually increased (climb or walk faster, pedal harder) while the patient is monitored. Electrocardiogram electrodes attached to the patient record tracings before, during, and after exercise. Additionally, blood pressure, physical appearance, and chest pain levels are monitored closely. 1-18. BLOOD STUDIES a. Electrolytes. Serum electrolyte studies are frequently performed on cardiac patients. Of particular significance are calcium, sodium, and potassium. (1) Calcium has a role in cell permeability, formation of bones and teeth, blood cell coagulation, nerve impulse conduction, and normal muscle contraction. Elevated calcium levels (hypocalcaemia) may cause HTN and cardiac arrest. Decreased calcium levels (hypocalcaemia) may cause tetany, convulsions, hypotension, and cardiac arrhythmias. (2) Sodium functions in maintaining the concentration of extra cellular fluid, acid-base balance, water balance, and nerve conduction. Elevated sodium levels (hypernatremia) may cause weight gain, pitting edema, HTN, and tachycardia. Decreased sodium levels (hyponatremia) may cause hypotension and tachycardia. If depletion is severe, vaso-motor collapse may occur. (3) Potassium is the dominant cellular electrolyte. It facilitates contraction of skeletal and smooth muscle to include myocardial contraction. Potassium is also concerned in acid-base balance, nerve impulse conduction, and cell membrane function. Both decreased potassium levels (hypokalemia) and increased potassium levels (hyperkalemia) diminish the excitability and conduction rate of the cardiac muscle. This may lead to bradycardia, tachycardia, cardiac arrhythmias, and cardiac arrest. b. Cultures. Blood cultures are performed to detect the presence of bacteria in the blood. This test is useful in the diagnosis of bacterial endocarditis. c. Enzymes. Enzyme studies are done to detect damage to the myocardium. The enzymes creatine phosphokinase (CPK) and lactic dehydrogenase (LDH) are found in increased levels after myocardial tissue damage. However, these enzymes are also

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present in other tissue, and blood levels may be elevated as a result of damage to skeletal muscles, the liver, the kidneys, and other organs. This results in a false positive. d. Isoenzymes. Isoenzymes are forms of enzymes that can be differentiated from one another. (1) One isoenzyme of the enzyme CPK is present in significant amounts only in myocardial tissue. This isoenzyme is identified as CPK-MB. (2) Lactic dehydrogenase has five isoenzymes, and cardiac muscle is associated with large amounts of the isoenzymes LDH1. (3) The determination of the isoenzymes (CPK-MB and LDH is more specific in evaluation myocardial damage than simple enzyme determinations. 1-19. PULSE a. Each time the heart beats, the left ventricle contracts and sends blood through the arteries. The pulse is the rhythmic expansion of the arteries that results from each heartbeat. The pulse may be felt most strongly over the following areas: (1) Radial artery in the wrist at the base of the thumb. (2) Temporal artery in front of the ear. (3) Carotid artery in the neck. (4) Femoral artery in the groin. (5) Over the apex (tip) of the heart (apical pulse). b. Two other locations for palpation of the pulse are the popliteal artery at the back of the knee and the pedal pulses of the foot. Pedal pulses are located on both the lateral and medial aspects of the ankle and on the top of the foot. These pulses are often difficult to locate. c. The physician may request that both a radial and apical pulse be taken simultaneously to see if there is a difference in rates. A significant difference is indicative of vascular disease. This difference between the apical and radial pulse is known as the pulse deficit.

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d. When the pulse is being counted, the rate, rhythm, and volume (force) should be noted. (1) Rate may be noted as normal, fast (tachycardia), or slow (bradycardia). An average pulse rate for a resting adult is 70-80 bpm (beats per minute). Rates faster than 100 bpm are considered to be tachycardia. Rates slower than 60 bpm are considered to be bradycardia. NOTE: A well-trained athlete may have a resting pulse of less than 50 bpm. (2) Rhythm is the regularity of the pulse beats. Rhythm is described as irregular when you can feel the pulsations occur at different rates. A normal rhythm has the same time interval between the beats. (3) Volume is the force or strength of the pulse. Terms used to describe the volume (force) of the pulse are weak, thready, or feeble for a pulse that lacks strength, and strong, full, or bounding for a pulse that feels forceful. Additionally, the force may be regular or irregular. e. There are many factors that affect the pulse rate. Some are listed below. (1) Sex. Women have a slightly faster pulse rate than men. (2) Age. The pulse rate gradually decreases from birth to adulthood then increases with advancing old age. (3) Body temperature. The pulse rate generally increases 7-10 beats for each degree of temperature elevation. (4) Digestion. The increased metabolic rate during digestion will increase the pulse rate slightly. (5) Pain. Pain increases pulse rate. (6) Emotion. Fear, anger, anxiety, and excitement increase the pulse rate. (7) Exercise. The heart must beat faster during exercise to meet the increased demand for oxygen. (8) Blood pressure. In general, heart rate and blood pressure have an inverse relationship. When the blood pressure is low, there is an increase in pulse rate as the heart attempts to increase the output of blood from the heart (cardiac output).

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1-20. BLOOD PRESSURE a. Blood pressure is defined as the pressure exerted by the blood on the walls of the blood vessels. When speaking of blood pressure, it is the arterial blood pressure that we are concerned with. When taking a patient's blood pressure with a sphygmomanometer and stethoscope, it is the arterial blood pressure that is being measured. b. Blood pressure is registered by two numbers that represent the pressures exerted during contraction and relaxation of the heart. (1) Systolic pressure is the maximum pressure occurring during systole, or contraction, of the ventricles. It is the higher of the two numbers. Normal systolic pressure for the average resting adult is between 100-150 mmHg. (2) Diastolic pressure is the pressure occurring during diastole, the period of relaxation and filling of the ventricles. This is the lowest pressure. Normal diastolic pressure for the average resting adult is between 60-90 mmHg. c. Blood pressure is best measured over a large artery. The most commonly used is the brachial artery. The cuff is wrapped around the upper arm and auscultation is done over the brachial artery in the antecubital space. (1) With extremely obese patients, the application of the cuff around the forearm and auscultation over the radial artery may give a truer measurement of blood pressure. (2) Blood pressure may also be taken in the leg by wrapping the cuff around the thigh and auscultating the popliteal artery behind the knee. (3) An accurate blood pressure reading depends upon the width of the cuff in relation to the diameter of the limb used. If the cuff is too large for the limb, as in a child, the reading obtained could be significantly lower than the true pressure. If the cuff is too small for the limb, as in an obese person, the reading obtained may be higher than the true pressure. d. Blood pressure depends upon the force of the heartbeat, the volume of blood in the circulatory system, and the resistance within the blood vessels. Other factors that affect blood pressure are: (1) Pain. Moderate to severe pain will increase blood pressure. (2) Emotions. Fear, anger, anxiety, or excitement will increase blood pressure.

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(3) Disease. Disease conditions may cause abnormal increase or decrease of blood pressure. e. In patients with hypertension or other cardiovascular disease, it is best to measure blood pressure in both the right and left arms. There should be no more than 5 mmHg difference between the two readings. A greater difference is indicative of vascular disease. f. The physician may order blood pressure checks to be done with the patient lying down, sitting, and standing. The corresponding rise or fall in pressure with the change of position may give the physician valuable information about the nature of the cardiovascular disease. g. Pulse pressure is the difference between the systolic and diastolic pressures. Normal range for pulse pressure should be 30-50 mmHg, with 40 mmHg the average. (1) A decreased pulse pressure (less than 30 mmHg) is related to factors that cause an increase in the diastolic blood pressure, a decrease in systolic blood pressure, or a combination of both. Causes of decreased pulse pressure included peripheral vasoconstriction, aortic valve stenosis, mitral valve insufficiency, or decreased stroke volume due to heart failure or hypovolemia. (2) An increased pulse pressure (greater than 50 mmHg) is related to factors that cause a decrease in the diastolic blood pressure, an increase in systolic blood pressure, or both. Causes of increased pulse pressure include hypertension, circulatory overload, arrhythmias, increased stroke volume caused by anxiety or exercise, or decreased distensibility of the arteries as seen in arteriosclerosis and aging.

Section III. CARDIOVASCULAR DISORDERS 1-21. CORONARY ARTERY DISEASE Coronary artery disease (CAD) is the condition in which the coronary arteries cannot deliver adequate blood supply to the heart muscle to meet the tissue demand. This condition is characterized by obstruction or narrowing of the vessel lumen. Coronary artery disease has been linked with certain "risk factors." In general, the more risk factors associated with an individual, the greater the chance for development of CAD. Some risk factors cannot be changed, while other risk factors can be modified or eliminated. Patient education is an important aspect of the nursing care of patients with CAD because the educated patient can take steps to improve his condition.

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1-22. RISK FACTORS. a. Risk factors that cannot be changed (non-modified) are age, sex, race, genetic make-up, and family history. b. The major risk factors, however, fall into the category of modifiable risk factors. Hypertension, elevated serum cholesterol levels, and cigarette smoking have been identified as the three major risk factors. These factors can be modified and controlled by taking prescribed blood pressure medication, modifying eating habits, and giving up cigarettes. c. Additional modifiable risk factors include weight, activity level, and stress levels. These factors can be controlled by maintaining an appropriate weight, making life style adjustments to reduce stress, and increasing physical activity. 1-23. ARTERIOSCLEROSIS a. Arteriosclerosis is the primary cause of CAD. Arteriosclerosis is defined as hardening or thickening of the arteries. Arteriosclerotic disease is characterized by thickening and loss of elasticity of the arterial walls. b. Atherosclerosis is the most common form of arteriosclerosis. Deposits of yellowish plaques (called atheromas) are formed within the medium and large sized arteries. These atheromas are made up of cholesterol, lipoid material, and lipophages (cells that ingest or absorb fat). 1-24. CORONARY HEART DISEASE a. Coronary heart disease (CHD) is a collective name for a number of ischemic diseases of the myocardium. Coronary heart disease is the eventual clinical manifestation of the effects of CAD. b. The major diseases of CHD are: angina pectoris, cardiac dysrhythmias, myocardial infarction, congestive heart failure, and sudden cardiac death. 1-25. ANGINA PECTORIS a. Angina pectoris is a clinical syndrome of ischemic heart disease, manifested by paroxysmal pain in the chest and adjacent areas. This disorder is considered to be an early warning of CV deterioration. The symptoms occur as a result of myocardial oxygen demand that exceeds the ability of the coronary arteries to deliver oxygen. (The coronary arteries supply the myocardium with the oxygenated blood it needs to work effectively.) The main cause for this inability to meet oxygen demand is the presence of aterosclerosis that causes advanced occlusion or stenosis of one or more of the three major branches of the coronary artery tree. The coronary arteries are illustrated in Figure 1-3.

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b. When the heart is stressed, it must rely on increased coronary blood flow to meet the increased oxygen demand of the cardiac tissue. Coronary blood flow is determined by the amount of pressure in the aorta and the amount of resistance in the coronary arteries. If atherosclerosis is present in the coronary vascular system, coronary blood flow is decreased because of the increased resistance in the coronary arteries. c. The pain of angina pectoris occurs when the heart is stressed or worked to a point where the oxygen demand is greater than the amount of oxygen that can be delivered. This usually occurs with some type of exertion, such as mowing the lawn, climbing stairs, or doing heavy housework. In the affected patient, the onset of pain will occur with exertion, and relief will normally occur with rest. Rest will decrease the workload on the heart, thereby decreasing the heart's oxygen demand and relieving the pain. d. Unstable angina pectoris is a term used to describe the exacerbation of the symptoms of angina pectoris. This syndrome is characterized by increased severity of symptoms, increased ease in provoking attacks of angina, and less predictability in controlling angina attacks. Symptoms may be severe enough to mimic an acute myocardial infarction. Crescendo angina and acute coronary insufficiency are also terms used to describe unstable angina. e. In either case, medical management is the same. The patient is educated about the nature of the disease so that it may be controlled with diet, medication, exercise, and risk factor modification. When the condition advances to the stage where it can no longer be controlled in this manner, surgical intervention may be indicated. Two surgical possibilities include the coronary artery bypass graft (CABG) and transluminal coronary angioplasty (balloon compression). 1-26. ACUTE MYOCARDIAL INFARCTION a. Acute myocardial infarction (AMI) results from an imbalance between oxygen demand and oxygen supply to the myocardium. In 90 percent of the cases of AMI, this imbalance is preceded by atherosclerosis and decreased blood flow in the coronary arteries. The inadequate blood flow results in decreased oxygen delivery to the heart muscle, which causes ischemia, injury, and death of a portion of the myocardium (infarction). b. Myocardial infarctions are described as being anterior, inferior, or posterior, depending upon the location of the infarcted area of the heart muscle. Infarcts can be further classified as being transmural or non-transmural. A transmural infarct (Non Q-Wave MI) is one that involves damage to the full thickness of the myocardium. A nontransmural MI involves only a partial thickness of the muscle.

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c. In the majority of patients with AMI, chest pain is the major presenting symptom. The pain is usually substernal and may radiate to the neck, shoulders, arms, or epigastric area. The pain is described as heaviness, constriction, burning, or similar to indigestion. It is important to remember, however, that there may be little or no pain present at all. AMI can be very subtle, and often difficult to distinguish from angina. In addition to chest pain, symptoms of MI include shortness of breath, diaphoresis, weakness, fatigue, anxiety, nausea, vomiting, abnormal blood pressure, and abnormal heart rate. d. Pain, anxiety, and arrhythmias occur in the early stages of MI. Ventricular fibrillation is the greatest threat to life in the first hours after MI. Medical management includes ECG monitoring, bedrest to reduce the workload of the heart, and intravenous therapy. Medications include morphine to reduce pain and relieve anxiety, vaso-dialators, beta blocker, calcium channel blockers and lidocaine as antiarrhythmic therapy. e. Nursing management of a patient with AMI is intensive in nature, requiring close monitoring of the patient's status and progress, along with concurrent patient education. The nursing staff works closely with the physician, physical therapist, and dietician to develop an individualized rehabilitation plan for the patient. This post myocardial infarction rehabilitation plan, often referred to as the "MI protocol," takes the patient from complete bed rest during the first days of his MI to discharge from the hospital several weeks later. The protocol is a plan of progressive, monitored "steps" of increased activity and exercise, accompanied by intensive patient education. The rehabilitation plan is implemented upon physician's orders once the patient's condition is stable. Rehabilitation is advanced by the physician, who bases his decisions upon daily review of the patient's status and the information recorded by the nursing staff. Important information regarding patient tolerance and acceptance of the rehabilitation process is obtained by the nursing staff and recorded in the patient's chart. f. Nursing care is directed toward three major considerations: observation and prevention of further myocardial damage and complications, promotion of an environment that allows for maximum comfort and rest, and patient education to fully prepare the patient for discharge. (1) Observation and prevention include the following nursing considerations: (a) Frequent monitoring of the patient's vital signs and ECG. (b) Observation for signs of impending heart failure by close monitoring of intake and output, daily weight, breathe sounds, and serum enzymes. (c) Careful assessment and documentation of each episode of chest pain to include severity, duration, medication given, and relief obtained.

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(2) Promotion of a restful and comfortable environment includes the following nursing considerations: (a) Provide emotional support to reduce anxiety and stress. (b) Orient the patient to the coronary care unit (CCU) routine and environment. Take time to explain procedures. (c) Schedule patient care activities carefully to avoid interrupting the patient's sleep. (3) Patient education is necessary to prepare the patient for resuming life outside the hospital setting. The following nursing considerations should be included: (a) Promote compliance with prescribed medications, diet, and other treatment measures by thoroughly explaining the need for each and the possible consequences of noncompliance. (b) Review all activity limitations and restrictions. (c) Counsel the patient on the action that should be taken when he is confronted with chest pain or other symptoms. 1-27. HEART FAILURE a. Heart failure is the clinical state in which there is inadequate cardiac output, resulting in poor perfusion of all organ systems. b. In left sided heart failure, the pumping action of the left ventricle is compromised, but the right ventricle continues to function normally. There is an imbalance between the out-put of each ventricle. The right heart continues to pump blood into the lungs to be oxygenated. The failing left heart, however, is unable to return that same volume of blood to the systemic circulation. The result is an accumulation of blood in the pulmonary blood vessels. Increased pressure in the pulmonary vessels causes fluid to leak into the interstitial lung tissue, compromising gas exchange. This condition is called pulmonary edema. c. Right sided heart failure usually follows left sided failure. The increased pressure in the pulmonary vessels causes "back pressure" to the right side of the heart. This interferes with venous return, and consequently, the organs of the body become congested. This condition, known as congestive heart failure (CHF), is manifested by neck vein distention and body edema. d. Right sided failure may occur without left sided failure. This condition, called corpulmonale, may be caused by pulmonary hypertension secondary to lung disease or by the presence of pulmonary emboli.

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e. Medical management of heart failure is twofold. The first concern of treatment is to stabilize the failure, relieving the edema and congestion. The second concern is to discover and treat the underlying cause of the failure. f. Nursing care of the patient with heart failure involves two major areas: nursing intervention during the acute phase of illness and patient education to prepare the patient for discharge. (1) During the acute phase, nursing considerations include the following: (a) Monitoring fluid retention by weighing the patient daily. (b) Monitoring intake and output. (c) Frequent assessment of vital signs. (d) Frequent monitoring of electrolytes. (e) Promoting mental and physical rest to reduce the workload of the heart. (f) Administration of prescribed medications to improve the heart's effectiveness as a pump. (g) Administration of prescribed dietary restrictions (sodium and fluids). (2) Patient education should include the following nursing considerations: (a) Instruction on effective coping mechanisms that will reduce stress in daily living. (b) Compliance in taking prescribed medications. (c) Compliance in following the prescribed dietary and fluid restrictions. (d) The importance of regular check-ups. 1-28. HYPERTENSION a. Hypertension (HTN) is defined as persistent levels of blood pressure with the systolic pressure greater than 150 mmHg and the diastolic pressure greater than 90 mmHg. Hypertension is a major cause of heart failure, kidney failure, and stroke.

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b. Hypertension is classified as primary and secondary. (1) Primary (or essential) HTN has no identifiable cause. Increased peripheral resistance is the basic cause for the elevated blood pressure, but the cause of the increased resistance is not understood. Drug therapy is aimed at decreasing the peripheral resistance, thereby lowering the blood pressure. (2) Secondary HTN is the result of a specific cause or disease process. Kidney disease, adrenal tumors, thyrotoxicosis, and preeclampsia are just a few examples. Therapy is aimed at both treating the elevated pressures and treating the primary cause. c. Hypertension is called the "silent killer" because it is often symptom free. When symptoms do occur, they are often mistakenly associated with other causes. Symptoms include headache, fatigue, nervousness, irritability, dyspnea, and edema. d. Continued HTN is damaging to the body. Medical management is aimed at lowering the blood pressure to alleviate the symptoms and to slow the progression of damage to the body. e. Nursing management involves intensive patient education to help the patient understand the nature of his disease and his role in keeping it under control. The nursing staff should reinforce the importance of the following: (1) Taking medications as prescribed. (2) Decreasing the use of tobacco and stimulants, such as caffeine. (3) Eliminating table salt and avoiding foods high in sodium, such as pickles, potato chips, cold cuts, and processed foods. (4) Controlling serum cholesterol levels by modifying the diet to avoid saturated fats. (5) Maintaining a weight appropriate to height and body type. (6) Altering one's lifestyle to minimize stress. (7) Following a regular exercise program. 1-29. VALVE DISORDERS a. The function of the heart's valves is to maintain the forward flow of blood from the atria to the ventricles and from the ventricles into the great vessels.

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b. Valvular damage interferes with this forward flow by stenosis (narrowing) of the valve or by impaired closure of the valve that allows a backward leakage of blood. This is called valvular insufficiency or regurgitation. c. If the heart muscle itself remains strong, the circulatory mechanisms can adjust and compensate for a bad valve. These modifications are called compensatory changes. d. Valve deficiencies cause two basic types of stress on the heart. If the stress produced is greater than the heart's ability to compensate, eventual deterioration will occur. The two types of heart stress associated with valve deficiencies are: (1) Pressure overload (associated with valvular stenosis). (2) Volume overload (associated with valvular insufficiency and regurgitation). 1-30. INFECTIVE ENDOCARDITIS a. Infective (bacterial) endocarditis is a microbial infection of endocardial tissue. The endocardium is the layer of tissue that lines the heart's cavities and covers the flaps of its valves. b. When an area of endocardium becomes inflamed, a fibrin clot called a vegetation may form. This clot will later form into a mass of scar tissue. The scarred endothelium becomes stiff, thick, and deformed. Vegetations on the valves may eventually cause chronic valvular disease. c. Endocarditis is categorized as either acute or subacute. This is determined by the virulence of the causative organism. (1) In acute infective endocarditis, the infecting organism is highly virulent, causing rapid and severe complications. (2) In subacute infective endocarditis, the infecting organism is of low virulence. Severe complications do not occur until late in the illness, if at all. d. Because standard medical treatment for infective endocarditis involves intravenous antimicrobial agents for a period of 4-6 weeks, the patient will require nursing intervention to prevent depression and alleviate the boredom that will result from the lengthy hospitalization. As the patient begins to feel better, he will feel confined and restricted by intravenous (IV).

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e. Nursing management of patients with endocarditis includes the following: (1) Obtain a history of allergies prior to the administration of antibiotics. (2) Ensure patency of IV and prevent the complications of long- term IV therapy. (3) Observe for signs and symptoms of complications such as CHF, renal failure, or emboli. (4) Educate the patient about his condition and the need for continued treatment and prophylactic antibiotics. (5) Teach the patient to recognize the symptoms of endocarditis and to seek medical assistance should symptoms recur.

Section IV. NURSING CARE OF THE CARDIOVASCULAR SURGICAL PATIENT

1-31. INTRODUCTION Through the use of modern techniques, it is possible for surgeons not only to repair damage or deformity of the large blood vessels but also to stop the heart, open it, and perform necessary surgery there. For purposes of discussion of nursing care, cardiovascular surgical patients may be considered under three general conditions: (1) those whose hearts have been opened or entered, as in surgery of the heart valves; (2) those in whom surgery is confined to the great vessels or to the exterior of the heart, as in coarctation of the aorta, patent ductus arteriosus, aneurisms, anastamoses, and non perforating wounds of the myocardium; and (3) those in whom surgery involves the major coronary arteries. 1-32. PREOPERATIVE CARE a. Most patients scheduled for cardiovascular surgery enter the hospital several days prior to surgery. This allows for adequate time to prepare the patient for what lies ahead and adequate time for the staff to develop a rapport with the patient. Establishing a trusting relationship with the patient will provide him with emotional support.

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b. A thorough assessment of the patient must be made. Many members of the health care team will be involved in this phase of preparation. (1) The physician must complete a thorough physical examination and patient history. He orders the lab work, X-rays, ECGs, and other studies that must be done to obtain baseline data on the patient's immediate preopcondition. (2) A nursing assessment of the patient must be done. This involves assessing the physical, psychological, social, and spiritual needs of the patient. (3) The dietician may visit the patient to do a nutritional evaluation and teach the patient about his new postoperative diet. (4) The physical therapist may visit the patient to instruct him in the postoperative procedures for his rehabilitation. Explanations will be given regarding the importance of advancing activity under the supervision of the staff, and exercise routines will be taught. (5) An assessment must be made of the patient's coping mechanisms. This may be done by the chaplain, the psychologist, or most commonly, by the nursing personnel. Poor coping mechanisms mean increased anxiety for the patient, and increased anxiety leads to a slower recovery. Early identification of this problem will allow the nursing staff to make provisions for it in the nursing plan of care. c. The nursing considerations in preoperative management include the following areas. (1) The nursing staff executes the physician's orders, gathers data, and keeps the physician up to date regarding the patient's status. (2) Patient education is implemented. The patient is instructed about his postoperative routine and the importance of his participation and cooperation during the postoperative course. (3) The patient must be fully oriented to the postoperative environment. This includes familiarization with the monitors, machines, and equipment that will be used during the postoperative period. If possible, give the patient a tour of the CCU and allow him to meet some of the nursing personnel. (4) Reduce patient anxiety by establishing a friendly informative, caring relationship with the patient.

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1-33. POSTOPERATIVE CARE Postoperative care for patients who have had surgery of the heart or great vessels is generally much the same as that given to other chest surgery patients. A possible exception to this generalization is care for the patient who has had surgery of the coronary arteries (see paragraph 1-33d below). The first 48 hours following cardiovascular surgery are the most critical, and a high degree of alertness and skill in nursing care are essential if death is to be prevented. Intensified nursing care should continue for at least the first five postoperative days. a. Vital Signs. Pulse, blood pressure, and respiration must be taken and recorded every 15 minutes until they stabilize, usually after 4-8 hours. In addition, cyanosis must be watched for and its cause corrected. A systolic pressure of only 80 or 90 in cardiovascular (CV) surgical patients is no cause for alarm as these patients tolerate the lower pressure well. The physician should be called immediately if the systolic pressure is below 80. The exception is the coronary artery surgical patient, whose pressure should be not more than 10 mm. below the preoperative pressure. The apical pulse, taken over the heart with a stethoscope, most immediately reflects the activity of the heart; however, the arterial pulse should be taken not only from the radial artery at the wrist, but also from arteries of all limbs to detect the presence of an embolus as early as possible. Temperatures outside the 97� to 102�F range should be reported. Higher temperatures may be an indication of shock or cardiac decompensation. The respiratory character as well as the respiratory rate should be noted. Using the stethoscope aids in detecting changes in character. Changes noted should be reported promptly. b. Oxygen Therapy. Oxygen is given by facemask, usually at the rate of 8 liters per minute. After the patient has fully reacted, a nasal cannula is substituted and oxygen is continued at 4 to 6 liters per minute until the physician orders discontinuance. Peripheral signs of cyanosis and ischemia must still be watched for, however. Mottling or blanching of the skin in an extremity--particularly if it is accompanied by other phenomena such as pain, numbness, tingling, or loss of motion--may indicate the presence of an embolus and should be immediately reported. c. Psychological Considerations. Any signs of disorientation, such as failure to recognize a member of the family or familiar surroundings, should be reported. A transient state of depression may be expected in the CV surgical patient. In an occasional patient, the depression will degenerate into suicidal tendencies. Postoperative depression may be prevented or its intensity lessened through preoperative explanation of the upcoming procedure and sympathetic consideration of the patient's fears and concerns. d. Positioning and Turning. Usually, the patient is kept in the dorsal recumbent position until his systolic pressure is more than 100. On specific orders from the physician, a CV surgical patient, other than one who has had coronary artery surgery, may be raised to a semi-Fowler position and may be turned from side to side

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every two hours. A blood pressure reading must be taken immediately before and 5 minutes after the patient is raised. If the blood pressure drops after the patient is raised, the head of the bed and the patient must be returned to horizontal for at least 30 minutes before the procedure is repeated. The coronary artery patient is usually kept in dorsal recumbent position for 48 hours before any attempt is made to change his position because, up to that time, turning the patient as little as 15 degrees to one side may cause a serious drop in blood pressure. When turning is permitted, the coronary artery patient should be turned from back to right side (and vice versa) every 2 hours. e. Pain. Ribs that were retracted during surgery are the major sources of postoperative pain in the CV surgical patient. During the first 24 to 48 hours, Demerol is given on a schedule and in a quantity sufficient to keep him reasonably comfortable but not enough to depress his mental outlook and cough reflex. After this initial period, other causes for continued restlessness--such as oxygen deprivation, fear, and positional discomfort--should be looked for and corrected. f. Cough. After stabilization, CV surgical patients should be encouraged to raise deeply lodged secretions by coughing with support in the same manner as other surgical patients. Such coughing is usually effective, but if it is not, endotracheal suctioning must be employed. Sometimes a mucolytic agent applied in aerosol form may be helpful. g. Underwater Seal Drainage. Nursing care with regard to CV patients with underwater seal drainage is generally the same as that for other chest patients with such drainage equipment in place. Drainage of about 400 to 500 ml of bloody fluid is to be expected from heart surgery patients during the first 24 hours. Absence of drainage fluid in the water seal setup indicates that fluid may be accumulating in the thorax. Thus, drainage volume must be carefully observed and recorded. h. Gastric Suction. Temporary gastric distention is a common occurrence in CV surgical patients. The stomach is intubated and suction applied to reduce distention and relieve any pressure exerted on the heart by the distended stomach. i. Diet. With permission of the physician, fluids may be given as soon as the patient can tolerate them. The first fluids given should be lukewarm and should not be fruit juices, as they may cause nausea. Cardiovascular surgical patients are normally markedly thirsty, and they will drink large quantities of fluids. If fluid is retained, intake may have to be restricted. Nursing personnel must diligently monitor and record fluid intake and output. Also, it may be necessary to weigh the patient daily. The physician probably will permit returning the patient to a soft or normal diet as soon as the patient desires solid food. Solid food should be withheld from the coronary artery surgery patient until abdominal cramps and gas no longer persist. j. Exercise. The patient, upon regaining consciousness, is encouraged to breathe deeply through the nose deliberately and quietly to ventilate and expand the lungs. Care must be taken not to tire the patient. Other voluntary body movement and

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exercise are encouraged after the first 24 hours. The patient is encouraged to comb his hair, reach for objects within normal reach, and then use a pull to raise himself. A pull may be made from wide gauze attached to the foot of the bed and extending to within the patient's reach. A T-handle may be inserted or a knot tied in the end of the pull to facilitate easier grasping. From about the 5th to the 8th day, as determined by the physician, the patient is allowed to dangle his feet for gradually increasing lengths of time, then gradually allowed out of bed more and more until the patient is fully mobile, usually by the 12th to 14th day. 1-34. COMPLICATIONS OF CARDIOVASCULAR SURGERY As has been stated above, the first 48 postoperative hours are the most critical, and intensive care should be continued for several days until the patient is out of grave danger. Respiratory problems, hemorrhage, and shock are problems associated with any major insult to the body. The following paragraphs discuss complications associated with insult to the CV system in particular. 1-35. THROMBOPHLEBITIS Thrombophlebitis is inflammation of a vein with blood clot formation. Venous stasis (slowing of venous blood circulation) and pressure or other injury to vein walls predisposes its development. The most common sites for development of thrombophlebitis are in the veins of the pelvis and legs. A postoperative patient or any other individual who has remained still for hours at a time with relaxed muscles and a resultant slowing of venous circulation in the legs is particularly liable to develop thrombophlebitis. When inactivity is combined with pressure on the popliteal space and the calf of the leg, the possibility of developing thrombophlebitis increases. a. Signs and Symptoms of Thrombophlebitis. (1) Cramping pain in the calf. (2) Possible redness, warmth, and swelling along the course of the involved vein. (3) Pain that may appear only on dorsiflexion of the foot. b. Nursing Implications. (1) Do not, under any circumstance, rub or massage the affected limb. (2) Place the patient on immediate bed rest and notify the RN.

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(3) Keep the affected limb horizontal and at rest until the physician has examined the patient and ordered specific treatment. Support the entire limb from the thigh to the ankle on pillows, keeping the limb level unless otherwise ordered. Orders for treatment may include elevation and application of continuous massive warm, moist packs to the entire limb. (4) Use a bed cradle to prevent any pressure from the bed linen. (5) Be alert to any complaint or other evidence of respiratory difficulty or chest pain. A clot which is adherent to the vein wall, or a portion of a clot, can become dislodged and be carried in the circulation as an embolus to distant and smaller arterial blood vessels in the lungs. Sudden dyspnea, violent coughing, or severe chest pain may be the first sign of embolism. (6) Discontinue routine postoperative exercise, ambulation, deep breathing, and coughing measures until the physician has indicated which measures are to be resumed and which precautions are to be taken. (7) Carry out all subsequent treatment and nursing care measures in a manner that will avoid abrupt movements and any strain on the part of the patient. (8) When ordered, apply anti-embolism hose or intermittent external pneumatic compression system to give support and aid venous circulation. (9) When the patient is allowed out of bed, remind him to alternate walking and resting with feet propped on a stool to avoid pressure in the popliteal space. Prolonged standing or sitting with no movement must be avoided. Check to see that the edge of the chair seat does not press the popliteal space and that the patient does not sit with crossed legs. 1-36. EMBOLISM An embolus is a blood clot or other foreign particle (fat globule or air bubble) floating in the bloodstream. The embolus is usually undetectable until it suddenly lodges in an arterial blood vessel. This may occur when the patient is apparently convalescing and progressing normally. If the embolus is sufficiently large and the arterial vessel which it obstructs supplies a vital area in the lungs, heart, or brain, the patient may die before any symptoms of embolism are detectable. A special type of embolism, pulmonary embolism, is caused by the obstruction of a pulmonary artery by an embolus. The most frequent cause of a postoperative pulmonary embolism is a thrombosed vein in the pelvis or lower extremities. Therefore, measures to prevent development of thrombophlebitis are the most important ones to take to prevent the possibly fatal complication of pulmonary embolism.

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a. Signs and Symptoms. NOTE: May or may not be observable. (1) Sudden signs of shock and collapse. (2) Sudden, sharp, stabbing chest pain. (3) Sudden violent coughing and hemoptysis (spitting of blood). (4) Pain, blanching, numbness, or coldness in an extremity. b. Nursing Implications. (1) Notify the registered nurse (RN) immediately. (2) Ensure absolute bed rest. Elevate head of bed to relieve respiratory distress. (3) Prepare to start oxygen by mask at 6 to 8 liters per minute. (4) Take and record blood pressure, pulse, and respiration. (5) Prepare to give medication by injection to relieve pain and acute apprehension. A narcotic drug such as morphine sulfate or meperidine hydrochloride is often ordered. (6) Prepare to continue intensive nursing care and constant observation. (The total care of the patient who survives a pulmonary embolism is similar to that of a patient who has had a myocardial infarction.) 1-37. ANTICOAGULANT DRUG THERAPY IN THROMBOPHLEBITIS AND

EMBOLISM a. General. Anticoagulant drugs such as heparin sodium and coumadin compounds lessen the tendency of blood to clot. They are frequently ordered as a part of the medical management of patients who have developed thrombophlebitis or who have survived an embolism. (1) These drugs do not dissolve thrombi that have already formed, but are an important treatment measure to prevent extension of a clot within a blood vessel or to prevent further intravascular clot formation. (2) Anticoagulant drugs act by prolonging the clotting time of blood.

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(3) Since a patient who has once developed thrombophlebitis may have a recurrence, he may be continued on an anticoagulant drug indefinitely as a prophylactic measure. b. Medical Considerations. (1) Drug dosage is regulated very carefully by the physician, in relation to the individual patient's prothrombin determination. (Prothrombin determination is a special blood test.) (2) Certain drugs should not be given with anticoagulants. Aspirin and aspirin-like drugs increase the effect of the anticoagulant. Phenobarbital and butazolidine decrease the effects. c. Nursing Implications. (1) Nursing personnel have a responsibility to recognize that any patient receiving an anticoagulant drug must be closely observed for bleeding. (2) Bleeding may occur from the mouth, nose, urinary tract, or rectum. (3) Patients receiving anticoagulant therapy should be encouraged to use a soft bristle toothbrush and an electric razor instead of a blade. (4) Local policy often dictates that only the RN may administer anticoagulant drugs. This is due to the potential hazards and complicated dosage orders. 1-38. CARDIAC TAMPONADE Bleeding into the pericardial sac, or accumulation of fluid in the pericardial sac, results in compression of the heart. This compression reduces heart movement, prevents adequate filling of the ventricles, and obstructs venous return to the heart. This condition, called cardiac tamponade, is an emergency that requires prompt relief to prevent death from circulatory failure. a. Signs and Symptoms. (1) Distention of the neck veins. (2) Weak pulse. (3) Low pulse pressure.

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NOTE: Delayed distention of the neck veins should not be confused with the transitory distention seen postoperatively as the patient throws off unconsciousness produced by anesthesia. This distention is usually the result of straining. b. Nursing Implications. (1) Report signs and symptoms to the RN immediately. (2) Monitor pulse and blood pressure. (3) Administer oxygen as ordered for dyspnea. (4) Assist with diagnostic procedures such as chest X-ray, ECG, or cardiac catheterization. (5) Assist with procedures to relieve pressure and remove fluid such as thoracotomy or needle aspiration of the pericardial cavity. 1-39. RENAL FAILURE a. Impairment of renal function may be caused by decreased cardiac output associated with open-heart surgery or by red blood count (RBC) hemolysis caused by the trauma of cardiopulmonary bypass. b. Nursing implications when renal failure is suspected include the following: (1) Strict and accurate recording of intake and output. (2) Measurement of urine output on an hourly basis. (3) If a urine output of less than 20 cc/hr is obtained, immediate notification should be made to the RN. (4) Routine specific gravity of urine should be performed and recorded. (Specific gravity provides information relative to kidney function.) 1-40. MYOCARDIAL INFARCTION a. A MI may occur during the postoperative period. Symptoms, however, may be masked by the postoperative pain being experienced by the patient.

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b. Nursing implications include the following: (1) A careful assessment of the patient's pain must be made in order to differentiate between routine postoperative discomfort and the pain associated with a myocardial infarction. (2) If MI has occurred, nursing management of the patient will encompass both postoperative and post-MI nursing care considerations.

Section V. SUDDEN CARDIAC DEATH 1-41. CARDIAC ARREST a. Cardiac arrest, also known as sudden cardiac death, is defined as the sudden, unexpected cessation of the heartbeat and circulation. This occurs when the heart action stops entirely or the heart fibrillates. Causes of sudden cardiac death include the following: (1) Cardiac arrhythmias. (2) Myocardial infarction. (3) Shock. (4) Drowning. (5) Electrocution. (6) Carbon monoxide poisoning. (7) Anoxia. b. The absence of peripheral pulses and heart sounds is all that is necessary to make the diagnosis. There is a period of about four minutes between the cessation of circulation and the onset of irreversible brain damage. For this reason, it is imperative that resuscitation begins immediately. Resuscitation requires that two basic life support functions be restored: blood must be pumped through the body and oxygen and carbon dioxide exchange must occur. Restoration of one function without the other is not adequate.

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1-42. THE PARAPROFESSIONAL ROLE a. The role of the nursing paraprofessional in cardiac arrest is one of extreme importance in saving a life, as the paraprofessional may be the first one to observe the emergency. It is necessary to have a well-planned course of action in mind at all times, in order to be prepared for an emergency. The nursing paraprofessional must: (1) Be proficient in cardiopulmonary resuscitation (CPR). (2) Be familiar with local standard operating procedures (SOP) for "CODE" procedures, including whom to call and how to reach them. (3) Be able to locate and operate emergency equipment. (4) Be ready to assist in the activities of code management at the direction of the physician or professional nurse. b. The following items are found in a standard "crash cart." (1) Emergency drugs. (2) Intravenous infusion equipment. (3) Needles and syringes. (4) Intubation equipment, oral airways. (5) Ambu bag with assorted masks and connecting tubing. (6) Oxygen equipment. (7) Suction equipment. (8) Assorted dressing materials. (9) There should be a defibrillator/cardiac monitor available if one is not located on or near the crash cart. c. It is not necessary for the paraprofessional to be familiar with every single item that is found in a crash cart or emergency kit. It is important, however, to be familiar with the cart and the general layout of its contents. This will save precious time in an emergency. All paraprofessional nursing personnel should be proficient in the use of oxygen and suction equipment.

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1-43. CODE a. Sudden cardiac death and the ensuing hectic activity involved in code management can be a frightening and anxiety producing experience for nursing personnel who are unaccustomed to this type of event. A basic understanding of what takes place during a code will do much to alleviate that anxiety. b. When a cardiac arrest has been identified: (1) The person who witnesses the event or discovers the patient will call for help from his co-workers and immediately initiate CPR. The co-workers will respond by initiating the procedures for "calling" a code. They will then obtain the emergency equipment, take it to the location of the code, and relieve or assist the individual performing CPR. As help arrives, several things begin to happen simultaneously: (a) An IV "lifeline" will be initiated. (b) Blood pressure readings will be obtained. (c) The patient is connected to the cardiac monitor. (d) Baseline blood work is drawn to assess the patient's status. (e) An ambu bag and oxygen will replace mouth-to-mouth resuscitation. (2) The physician in charge will make decisions based on his observations of the patient's condition and the response to CPR. If there is no response to CPR, the code continues, and again, several things happen simultaneously: (a) The patient will be intubated. (b) Appropriate emergency drugs will be administered. (c) Cardiopulmonary resuscitation is continued while the electrical activity of the heart is observed on the cardiac monitor. If appropriate to the patient's condition, the patient will be defibrillated. (d) Blood samples are drawn repeatedly to monitor the effectiveness of the treatment. Acid-base balance and adequacy of oxygenation are of extreme concern. (3) These procedures continue until the patient is stabilized or the physician makes the determination to declare the patient dead.

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c. The seeming confusion of people is actually a coordinated effort by a group of people, each performing a particular task. The major roles are as follows: (1) A physician will direct the activities, "managing" the code. (2) A nurse will administer IV medications at the direction of the physician in charge. (3) A nurse (or paraprofessional) will monitor blood pressure and obtain blood samples. (4) One individual will perform chest compressions. (5) One individual will administer artificial ventilation. This is normally the anesthesia specialist, who has intubated the patient. (6) One individual will act as a recorder, charting the exact time of each action performed and each medication given. (7) One or more individuals act as "runners," taking specimens to the lab, obtaining needed supplies, receiving lab reports, and so forth. d. Remember, the purpose of a "code" is to attempt resuscitation of a patient whose heart has stopped pumping effectively (fibrillation) or stopped pumping altogether. Keep this purpose in mind at all times, and be aware of your role as a paraprofessional. 1-44. CONCLUSION a. This lesson has introduced the basic nursing care techniques and procedures involved in the nursing care related to the CV system. b. Review the lesson's objectives once again. If you feel confident that you have achieved the lesson objectives, complete the exercises at the end of this lesson. c. If you do not feel that you have met the lesson objectives, review the necessary material before you attempt the end of lesson exercises.

Continue with Exercises

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EXERCISES, LESSON 1 INSTRUCTIONS: Answer the following exercises by marking the lettered response that best answers the question, by completing the incomplete statement, or by writing the answer in the space provided. After you have completed all of these exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers. For each exercise answered incorrectly, reread the material referenced with the solution. SPECIAL INSTRUCTIONS FOR EXERCISES 1 THROUGH11. Exercises 1-11 should be answered by filling in the blanks to identify the heart structures in the figure below.

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12. The two fluid transportation systems of the circulatory system are the ________________________ and the __________________________. 13. The chambers of the heart are lined with ________________________. 14. Blood from the upper part of the body enters the heart through a blood vessel called the ___________________________. 15. Blood flows from the right ventricle into the ________________________. 16. Systemic circulation starts from the _________________________, and the pulmonary circulation starts from the ______________________________. 17. The heart gets its blood supply from the _________________________. 18. The wave of expansion and recoil of an artery associated with the heartbeat is called the ______________________. 19. Cardiac fluoroscopy is used to show the heart in ___________________. 20. The procedure in which a radiopaque catheter is manipulated through the heart is called ______________________. 21. The graphic recording of the electrical impulses produced by the heart is called an _________________________. 22. The five major waves of the ECG are: _____, _____, _____, _____, and _____

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23. Which ECG wave represents atrial depolarization? a. T b. P c. R d. Q 24. Which ECG wave represents electrical recovery of the ventricles? a. P b. R c. T d. S 25. The chest lead that is placed over the 5th intercostal space at the midclavicular line is the ______________________ 26. The difference between the apical and radial pulse is called the ___________________________. 27. _____________________________ is the force or strength of the pulse. 28. List three terms used to describe the volume or force of a pulse. ___________________________________ ___________________________________ ___________________________________

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29. Which of the following is NOT a factor that may affect pulse rate? a. Body temperature. b. Blood pressure. c. Digestion. d. Pain. e. None of the above. 30. The pressure that occurs during contraction of the ventricles is called ___________________ 31. Fear, anger, or anxiety will cause blood pressure to _________________. 32. The difference between the systolic and diastolic pressures is called the ________________________________ 33. The condition in which the coronary arteries cannot deliver adequate food supply to the heart is referred to as ________________________________. 34. Which of the following is NOT a modifiable risk factor? a. Cigarette smoking. b. Weight. c. Sex. d. Stress. 35. _______________________ is the most common form of arteriosclerosis. 36. A clinical syndrome of ischemic heart disease, in which pain occurs in the chest or adjacent areas, is called _________________________________

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37. The pain of angina usually occurs during __________________ and is relieved with ______________________. 38. A non-transmural myocardial infarction involves_______________________ _____________________________ 39. _______________________ is the greatest threat to life in the first hours after a myocardial infarction. 40. The clinical condition in which inadequate cardiac output results in poor perfusion of organ system is called____________________________ 41. When increased pressure in the pulmonary vessels causes fluid to leak into the interstitial lung tissue, ______________________________ occurs. 42. The condition manifested by neck vein distention and body edema is called ___________________________ 43. Hypertension that has no identifiable cause is referred to as _________________ hypertension. 44. For a cardiovascular surgical patient, poor ________________________ result in increased anxiety, which leads to a slower recovery. 45. Cramping pain in the calf and the appearance of swelling or redness along a vein are signs of ________________________________. 46. Compression of the heart from fluid accumulation in the pericardial sac is called __________________________________. 47. Why is it essential for paraprofessional nursing staff to be familiar with the layout of a crash cart? _________________________. 48. What does the recorder do during a "code?" ___________________________.

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49. Sudden, sharp, stabbing chest pain and violent coughing in a post-operative CV surgical patient may indicate the present of _________________________. 50. Right sided heart failure without left sided failure is called _________________.

Check Your Answers on Next Page

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SOLUTIONS TO EXERCISES, LESSON 1 1. Pulmonary vein (Figure 1-2) 2. Right atrium. (Figure 1-2) 3. Pulmonary valve. (Figure 1-2) 4. Tricuspid valve. (Figure 1-2) 5. Right ventricle . (Figure 1-2) 6. Aorta. (Figure 1-2) 7. Pulmonary artery. (Figure 1-2) 8. Left atrium. (Figure 1-2) 9. Mitral valve. (Figure 1-2) 10. Aortic valve. (Figure 1-2) 11. Left ventricle. (Figure 1-2) 12. Cardiovascular system, lymphatic system. (para 1-1a, b) 13. Endocardium or endocardial tissue . (para 1-2d) 14. Superior vena cava. (para 1-3) 15. Pulmonary artery. (para 1-3b) 16. Left ventricle; right ventricle. (para 1-3e) 17. Coronary arteries. (para 1-4a) 18. Pulse. (para 1-6a) 19. In action (or motion). (para 1-12) 20. Cardiac catheterization. (para 1-15 b) 21. Electrocardiogram. (para 1-16a) 22. P, Q, R, S, T. (para 1-16b)

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23. b. (para 1-16b) 24. c. (para 1-16b) 25. V4 lead. (para 1-16e) 26. Pulse deficit. para 1-19c) 27. Pulse volume. (para 1-19d) 28. Weak, thready, feeble, bounding, full, or strong. (para 1-19d) 29. e. (para 1-19e) 30. Systolic (or systole). (para 1-20b) 31. Increase (rise). (para 1-20d) 32. Pulse pressure. (para 1-20g) 33. CAD (coronary artery disease). (para 1-21) 34. c. (para 1-22a) 35. Atherosclerosis. (para 1-23b) 36. Angina pectoris. (para 1-25a) 37. Exertion; rest. para 1-25c) 38. Only partial thickness of the myocardial muscle. (para 1-26b) 39. Ventricular fibrillation. (para 1-26d) 40. Heart failure. (para 1-27a) 41. Pulmonary edema. (para 1-27b) 42. Congestive heart failure. (para 1-27c) 43. Primary or essential. (para 1-29b) 44. Coping mechanisms. (para 1-32b(5)) 45. Thrombophlebitis. (para 1-35a)

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46. Cardiac tamponade. (para 1-38) 47. To save time in an emergency. (para 1-42c) 48. Chart the exact time of each drug given and each procedure performed. (para 1-43c) 49. Embolism. (para 1-36a) 50. Corpulmonale. (para 1-27d)

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